Every finding on record at Pine Point Center

Based on record review and interview, the facility failed to ensure physician standing orders for constipation, including physician notification, were implemented for 1 of 33 sampled residents. (#16) Finding: Resident #16 was admitted to the facility on [DATE] with a past medical history including a right hemicolectomy and chronic constipation. Review of Resident #16's clinical record revealed no documented bowel movement from 6/14/26 through 6/23/26. (10 days) A small bowel movement was documented on 6/24/26. The June 2026 Medication Administration Record (MAR) revealed the resident received Miralax daily scheduled for constipation from 6/3/26 through 6/27/26. Review of Resident #16's physicians orders dated 6/3/26 instructed staff to administer Sorbitol Solution 70%, 30 milliliters (ml) by mouth daily as needed for constipation. The MAR indicated Resident #16 received Sorbitol on 6/23/23 and 6/27/26. In addition, Resident #16's physician standing orders dated 1/2/26 revealed staff were instructed to implement the facilities constipation protocol as follows: If no bowel movement for 3 shifts (24 hours), a.m. shift give prune juice as patient tolerates.If no results for 24 hours, a.m. give sorbitol 30 ml's by mouth x 1 doseIf no results by evening shift, post sorbitol, give bisacodyl 10 milligrams (mg) suppository 1 per rectum (PR) x 1 dose.If no results post suppository, NOTIFY PROVIDERIf sorbitol given more than 2 x per month, NOTIFY PROVIDER. Review of Resident #16's care plan revealed the resident was identified as being at risk for gastrointestinal symptoms and complications related to chronic constipation. The care plan goal was for the resident to have formed bowel movement every 3 days. Interventions included monitoring and documenting bowel movements, implementing the bowel regimen, and evaluating the effectiveness of interventions, and assessing and reporting decreased bowel movements and other signs and symptoms of constipation. Review of the clinical record lacked evidence that the resident was assessed following the absence of bowel movements for 10 days, the physician's standing orders for constipation were fully implemented, or the physician was notified when constipation interventions were ineffective. Resident #16 was transferred to the emergency department for abdominal pain and constipation on 6/27/26 and was subsequently admitted to the hospital. Hospital admission records indicated resident was diagnosed with a 7.9-centimeter rectal fecal impaction with findings consistent with stercoral colitis requiring disimpaction. During an interview on 7/16/26 at 12:15 p.m., the Director of Nursing (DON) acknowledged the physician should have been notified when constipation interventions were ineffective and confirmed the facility was unable to provide documentation that the physician was notified.

Based on record review and interview, the facility failed to ensure a resident with a specialized mental health diagnosis, whose stay went beyond the number of approved days(30 days), had been referred to the appropriate state-designated authority for a Pre-admission Screening & Resident Review Level II(PASRR) evaluation and determination for 1 of 3 residents reviewed for PASRR (Resident #15 [R15]).Finding:On 7/15/26, clinical record review indicated R15 was admitted in June of 2026 with diagnosis to included Major Depressive Disorder. Review of R15's PASRR, dated 6/12/26, indicated R15 had a Mental Health Disability with an approval of 30 days. On 7/15/26 at 11:39 a.m., in an interview with a surveyor, the Regional Director of Clinical Operations confirmed that Resident #15 has been at the facility for longer than the approved 30 days and that the resident had not been referred to the appropriate state-designated authority for a new Pre-admission Screening & Resident Review Level II(PASRR) evaluation and determination.

Based on facility policy, record review and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 3 residents reviewed for falls (Resident #3) and 3 of 3 residents reviewed for Medication Administration Records (MAR) and Treatment Administration Records (TAR) (Resident #1, #3, and #4). Findings: Facility Policy titled Falls Management states; Any patient who sustains a injury to the head from a fall and/or has a fall unwitnessed by staff will be observed for neurological abnormalities by preforming neurological checks, per facility policy. Facility Policy titled Neurological Evaluations states; Neurological evaluations will be performed: Every 15 minutes x two hours, then every 30 minutes x two hours, then every 60 minutes x four hours, then every 8 hours until at least 72 hours has elapsed. 1. On 6/2/26 a review of Resident #3's clinical record showed he/she sustained an unwitnessed fall on 4/19/26. Further review of the record showed a telehealth visit on 4/19/26 at 1:00 a.m., in which the provider wrote staff are to Monitor per facility protocol with neuros as it was unwitnessed. A review of Resident #3's Neurological Evaluation Flow Sheet showed 4 missing neurological evaluations. On 6/2/26 at 1:30 p.m., during an interview with the Market Clinical Advisor, the above information was discussed. 2. On 6/2/26 a review of Resident #3's MAR/TAR for the month of May revealed; -A physician order dated 3/12/24 for Vital signs Short Term/Skilled pt [patient] q(every) shift x72 hours, then daily every evening shift. A review of the medical record lacked evidence that vital signs were completed on 5/5/26. - A physician order dated 4/24/26 for Wound Monitor: coccyx. Monitor site daily for status of surrounding tissue and wound pain. Monitor status of dressing, if applicable. every shift. A review of the medical record lacked evidence that wound monitoring was completed on 5/4/26, 5/5/26, and 5/6/26. - A physician order dated 4/24/26 for Wound Treatment: MASD (Moisture Associated Skin Damage)- coccyx. Cleanse with soap and water, apply orange cap (protect) BID (twice a day) and with any incontinence episode. A review of the medical record lacked evidence that wound treatments were completed on 5/4/26, 5/5/26, and 5/6/26. On 6/2/26 at 1:30 p.m., during an interview with the Market Clinical Advisor, the above information was discussed. 3. On 6/2/26 a review of Resident #1's MAR/TAR for the month of May revealed: -A physician order dated 3/19/26 to Apply tubigrip (Tubi grip) size F from base of toes to knee [NAME]. On in morning, off in the evening - may leave 24/7 (for) dressing securement and change on dressing days in the morning for Edema and remove per schedule. A review of the medical record lacked evidence that the Tubi grip was applied on 5/4/26. -A physician order dated 11/14/24 to Monitor Swallowing during med pass: Document Y/N in supplementary documentation Did the patient cough when swallowing medications? Did the patient complain of or demonstrate pain or difficulty when swallowing medications? every day and evening shift If new onset or worsening request Speech Therapy Screen and complete EInteract Change In Condition, if not new initiate applicable care plan Interventions and document interventions and effectiveness in progress notes. A review of the medical record lacked evidence that swallowing was monitored on 5/4/26. -A physician order dated 11/13/24 for Non-Pharmacological Intervention (s) document Qshift Record Non-Pharm intervention in Supplementary Documentation. Document Effectiveness. If having pain follow providers direction which may include pain medication. every shift. A review of the medical record lacked evidence that non-pharmacological interventions were done on 5/4/26. -A physician order dated 4/8/26 for Wound: Cleanse wound, pat dry, apply Aquacel Ag to all wound bases, cover with ABD (abdominal) pad, conform to secure. Wrap with Coflex zinc lite. one time a day every Mon, Wed, Fri. A review of the medical record lacked evidence that wound treatment was done on 5/4/26. On 6/2/26 at 3:40 p.m. in an interview with two surveyors the Market Clinical Advisor confirmed the above MAR omissions. 4. On 6/2/26 a review of Resident #4's MAR/TAR for the month of May revealed: -A physician order dated 8/28/25 to Apply Petroleum to Bilateral feet/toes BID (two times a day) every day and evening shift for skin integrity. A review of the medical record lacked evidence that petroleum was applied on 5/4/26, 5/11/26, 5/17/26, 5/25/26, and 5/26/26. -A physician order dated 2/16/26 to Ask resident if they are having pain. Document pain level and new onset Y/N in supplementary documentation and document location of pain in emar PN every shift If new onset complete EInteract Change In Condition and Pain Evaluation, if not new initiate non-pharmalogical Interventions and document interventions and effectiveness. A review of the medical record lacked evidence that the Resident was asked about their pain level on 5/17/26. -A physician order dated 5/8/26 to Check air mattress Qshift. Settings-therapy:static, comfort:5, medium, cycle time:25 mins every shift for monitoring. A review of the medical record lacked evidence that the air mattress was checked on 5/17/26. -A physician order dated 6/6/26 for Does the patient need to have the Head of Bed Elevated to Avoid Shortness of Breath while lying flat? every shift for SOB. A review of the medical record lacked evidence that the head of the bed was assessed if it was elevated on 5/17/26. -A physician order dated 11/26/25 for Fluid Restriction - Total: 2000mLs/24 hours Document Qshift amount in supplemental documentation every shift for CHF 1000mLs on day shift 600mLs on evening shift 400mls on night shift'. A review of the medical record lacked evidence that the fluid restriction was completed on 5/4/26, 5/5/26, 5/11/26, 5/17/26, 5/19/26. 5/25/26, 5/26/26, and 5/27/26. -A physician order dated 8/22/25 for May keep and apply own supply of generic TAO w/ pain relief. every shift. A review of the medical record lacked evidence that the order was acknowledged on 5/17/26. -A physician order dated 4/8/26 for Micatin Cream 2 % (Miconazole Nitrate) Apply to perineal, groin topically two times a day for rashes. A review of the medical record lacked evidence that Micatin cream was applied on 5/4/26, 5/11/26, 5/17/26, 5/18/26, and 5/25/26. -A physician order dated 3/16/26 to Monitor for side effects of antidepressant medication due to use of Duloxetine and Bupropion. every shift Enter Side Effect Code in supplemental documentation: N: None DM: dry mouth, V: blurred vision, CO: constipation, U: urinary retention, H: hypotension, A: appetite changes, HA: headache, I: insomnia, DP: dyspepsia, WC: weight changes. A review of the medical record lacked evidence that side effects were monitored on 5/17/26 and 5/18/26. -A physician order dated 4/6/26 to Monitor for side effects of antidepressant medication every shift Enter Side Effect Code in supplemental documentation: N: None DM: dry mouth, V: blurred vision, CO: constipation, U: urinary retention, H:hypotension, A: appetite changes, HA: headache, I: insomnia, DP: dyspepsia, WC: weight changes. A review of the medical record lacked evidence that side effects were monitored on 5/17/26. -A physician order dated 4/8/26 to Monitor R (right) elbow cellulitis, groin, perineal area Daily for status of surrounding tissue and wound pain. Monitor for status of dressing (s), if applicable Additional Documentation in NN if needed every shift. A review of the medical record lacked evidence that this was monitored on 5/4/26. -A physician order dated 4/6/26 to Monitor socially withdrawn behaviors Q Shift. Indicate the number of occurrences followed by the NPI #provided. If no behaviors, select not applicable every shift NPI:1 Music/TV 2 Redirect/divert 3 Call fam/RP to talk or visit w/ res 4 Toilet 5 1:1 talk 6 Reassure/orient 7 Assess pain/infec 8 Offer drink/snack 9 Quiet environment 10 Walk/wheel 11 activity /exercise 12 massage/back rub. A review of the medical record lacked evidence that the resident was monitored for social withdrawal on 5/4/26, 5/1/26, 5/17/26, 5/18/26, and 5/25/26. -A physician order dated 6/6/26 for order Non-Pharmacological Intervention (s) document Qshift Record Non-Pharm intervention in Supplementary Documentation. Document Effectiveness. If having pain follow providers direction which may include pain medication. every shift for pain. A review of the medical record lacked evidence that non-pharmacological interventions were documented on 5/4/26, 5/17/26, 5/18/26, and 5/25/26. -A physician order dated 1/8/26 for order Patient and family education heart failure management to include daily weight monitoring, symptom monitoring, medications, and diet (low sodium/fluid restriction if applicable) mark appropriate selection. every day and evening shift for CHF protocol Document response to education: (via supplemental documentation). A review of the medical record lacked evidence this education was done on 5/4/26, 5/17/26, and 5/18/26. -A physician order dated 6/24/25 for Vital Signs Short Term/Skilled Pt q shift x72 hrs then daily every day shift for skilled. A review of the medical record lacked evidence that vital signs were done on 5/18/26. -A physician order dated 5/11/26 for weigh one time a day every Mon. A review of the medical record lacked evidence that a weight was obtained on 5/11/26 and 5/18/26. -A physician order dated 5/15/26 for WOUND MONITOR: Right elbow, Left foot, 1st digit and left 2nd digit. Monitor daily for status of surrounding tissue and wound pain. Monitor for status of dressing, if applicable Additional Documentation in NN if needed every shift. A review of the medical record lacked evidence that the wound was monitored on 5/17/26, 5/18/26, 5/25/26, and 5/26/26. -A physician order dated 12/22/25 for WOUND MONITOR: Right leg, Left foot, 1st digit. Monitor daily for status of surrounding tissue and wound pain. Monitor for status of dressing, if applicable Additional Documentation in NN if needed every shift. A review of the medical record lacked evidence that the wound was monitored on 5/4/26. -A physician order dated 5/7/26 for WOUND TREATMENT: Diabetic - Left foot, 1st digit: Skin prep area daily. WOUND nurse will be in week of 5/18 to par callus and clean wound. every day shift. A review of the medical record lacked evidence that the wound was treated on 5/17/26, 5/18/26, 5/25/26, and 5/26/26. -A physician order dated 5/7/26 for WOUND TREATMENT: Skin tear - Left elbow: Skin prep daily until resolved. every day shift. A review of the medical record lacked evidence that the wound was treated on 5/11/26, 5/17/26, 5/18/26, 5/25/26, and 5/26/26. -A physician order dated 5/16/26 for Wound: left 2nd digit, cleanse with wound cleanser, apply medi honey and cover with opti foam one time a day. A review of the medical record lacked evidence that wound treatment was done on 5/17/26, 5/18/26, 5/25/26, and 5/26/26. -A physician order dated 3/19/26 to Wrap LLE (lower left leg) with Kerlix + Coban one time a day every 2 day(s) for edema. A review of the medical record lacked evidence that the leg was wrapped on 5/18/26 and 5/26/26. On 6/2/26 at 3:40 p.m. in an interview with two surveyors the Market Clinical Advisor confirmed the above MAR omissions.

Based on record review and interviews, the facility failed to clarify hospital discharge orders and provide a brand name medication for a resident for 1 of 3 residents reviewed for medications. Findings:During a medical record review, Resident #3's hospital Discharge summary, dated [DATE], Medications to continue, levothyroxine 112 mcg(microgram) tabs- take 112 mcg by mouth. Commonly known as: Synthroid, PATIENT TAKES BRAND NAME. Discharge Summary also included TSH level was 1.48 (5/9/23) (last known level).Medication Administration Record (MAR) for January, indicated Levothyroxine Sodium tab, 112 mcg. Start Date 1/21/26. End date 1/31/26.On 5/27/26 at 12:16 p.m., during an interview with the family, stated, Our family communicated repeatedly since admission that [Resident #3] cannot tolerate generic levothyroxine. Family indicated that the resident's husband has delivered brand-name Synthroid directly from home to the facility for this reason.Medication Administration Record (MAR) for February and March indicated Synthroid Oral Tablet, 112 mcg (Levothyroxine Sodium), give 1 tablet by mouth one time a day for low thyroid hormone may use home supply until arrives from pharmacy.Pharmacy Shipping Manifest indicated Levothyroxine 112 mcg was delivered to facility on 1/20/26, 2/1/26, 2/11/26, and 3/17/26.Lab Report, dated 5/12/26, indicated TSH levels 26.6 (ref range0.270-4.200). At this time, physician documented and ordered name brand Synthroid.The medical record lacked evidence the facility clarified Discharge Summary orders that indicted Patient takes Brand Name for Synthroid for approximately three months.

Based on record reviews and interviews, the facility failed to follow up on laboratory orders when there were no results for a lab ordered for 1 of 3 residents whose record was reviewed for thyroid treatment (Resident #3).Findings:1. Resident #3's medical record indicated an order for Comprehensive Metabolic Panel (CMP), Complete Blood Count with Diff (CBC with diff), and Thyroid Stimulating Hormone, (TSH), dated 3/10/26. The lab results included CMP and CBC with diff, however, lacked evidence of TSH.2. Resident #3's medical record indicated an order for Comprehensive Metabolic Panel (CMP), Complete Blood Count without Diff (CBC w/o diff),and Thyroid Stimulating Hormone, (TSH), dated 4/5/26. The lab results included CMP and CBC with diff, however, lacked evidence of TSH.On 6/2/26 at 1:36 p.m., during an interview with two surveyors, the Marketing Clinical Director stated labs were drawn in March and April however, the lab did not process them for TSH even though it was requested. At this time, she confirmed there was no follow-up to the provider regarding the TSH labs to be redrawn.

Based on observations, interviews and record reviews, the facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to hand hygiene during medication administration and meal tray service observations and the use of Personal Protective Equipment (PPE) for 3 of the 4 days of survey. Findings: 1. On 4/7/25 at 8:02 a.m., just prior to medication administration observation, the Licensed Practical Nurse #2 (LPN #2) was observed at the nurse's station rubbing his eyes and nose multiple times. He then moved the medication cart onto Pleasant Hill House and without preforming hand hygiene prepared a resident medication, again rubbing eyes and nose, he then entered resident room, removed and applied a Lidoderm patch to the residents back, then administered the resident's medications all without performing hand hygiene. At this time, the LPN#3 stated, due to a condition, he frequently rubs his eyes, and he should have performed hand hygiene prior to preparing and administering medications. On 4/7/25 at approx. 8:30 a.m., the above was discussed with the Market Clinical Advisor 51331 2. On 4/7/25 at 12:25 p.m., during lunch meal pass on the Skilled Unit, a surveyor observed CNA #2 and CNA #3 turning and boosting a resident in his/her bed, both CNA's exited the residents room and without performing hand hygiene, CNA #2 grabbed a meal tray and delivered it to room [ROOM NUMBER] and CNA #3 grabbed a meal try and delivered it to room [ROOM NUMBER]. At 12:27 p.m., at this time the surveyor intervened, both CNA #2 and CNA #3 confirmed they should have performed hand hygiene after providing care to a resident and prior to tray delivery. On 4/7/25 at 1:00 p.m., the above information was discussed with the Market Clinical Advisor. 51669 3. On 4/8/25 at 4:04 p.m., a Physical Therapy Assistant (PT-A) was observed exiting the Oak Hill unit, wearing a yellow isolation gown. The PT-A proceeded to walk past the surveyor, located next to the nurse's station and enter the main dining room, where she doffed the isolation gown and then exited the dining room. At this time, the surveyor asked where the PT-A was prior to leaving the Oak Hill unit, and the PT-A stated she had been in a room wearing gloves, a gown, an N95 mask, and eye protection because the resident was on transmission-based precautions (TBP). She then stated, while she was in the room with the resident, the nurse came in and informed her that the TBP had just been lifted and she removed her gloves, mask, and eye protection before she exited the room and should have removed the gown, but she forgot, so she doffed it in the dining room. On 4/8/25 at 4:11 p.m., the above was discussed with the Market Clinical Advisor.

Based on interviews and record review the facility failed to review and revise the care plan by an interdisciplinary team (IDT) meeting, which included the participation of the resident and resident's representative, after each Minimum Data Set (MDS) 3.0 assessment, for 3 of 10 residents whose care plans were reviewed. (Resident #22, #40, #11) Findings: 1. Resident #22's medical record contained a Significant Change MDS, dated [DATE], and Quarterly MDS' dated 8/9/24, 11/7/24, and 1/29/25. The record lacked evidence of IDT meetings being held within 7 days of the above MDS assessments. The medical record stated the last IDT meeting was held on 3/12/24. On 4/8/25 at 11:20 p.m., the above information was discussed with the Market Clinical Advisor. 37015 2. Resident #40's clinical record contained Quarterly MDS' dated 12/13/24 and 3/15/25. The record lacked evidence of IDT meetings being held within 7 days of the MDS assessment. In addition, the Admission MDS dated [DATE] had a IDT meeting held on 9/16/24 with the resident in attendance, but not the family representative. On 4/8/25 at 2:27 p.m., during an interview, the Market Clinical Advisor confirmed that IDT meetings had not been held and there was no evidence that Resident #40's representative had been invited or had been provided with a copy of the resident care plan. 51669 3. Resident #11's clinical record contained a Quarterly MDS Assessment, dated 1/11/25. The record lacked evidence of IDT meetings being held within 7 days of the MDS assessment. On 4/9/25 at 10:21 a.m., during an interview, the Social Services Director confirmed she does not have a process for scheduling IDT meetings and does not usually provide residents or their representatives advance notification of the meeting(s).

Based on record review and interviews, the facility failed to assess and monitor a surgical wound ( Resident#57), failed to follow physician orders for a wound care ( Resident#27) for 2 of 2 resident reviewed for wounds. In additon, the facility failed to obtain physician orders for 1 of 1 resident reviewed for positioning. (Resident #4) Findings: 1. Resident #57 was admitted to the facility in September of 2024, after having a left intertrochanteric femur fracture operation leaving him/her with a surgical wound. Review of the Treatment Administration Record indicated that he/she had Suture/staple removal one time only for Post op left proximal femur on 10/6/24. Upon further review, the medical record lacked evidence of an initial nursing assessment, continued monitoring, and assessments of the surgical site throughout his/her stay. On 4/8/25 at 11:20 p.m., the above information was confirmed with the Market Clinical Advisor. 51669 2. On 4/6/25 at 10:02 a.m., and on 4/7/25 at 12:16 p.m., Resident #27 was observed with an uncovered, open wound on his/her right forearm. Resident #27's clinical record contained a physician order dated 4/3/25 for, Mupirocin External Ointment 2 % (Mupirocin) Apply to Right forearm topically every evening shift for Biopsy for 11 Days. Cover with Band aid, Per dermatology On 4/9/25 at 10:30 a.m., during an interview, the Registered Nurse #2 stated Resident #27's right forearm wound is supposed to be covered with a bandage at all times. At this time, the finding was reviewed with the Unit Manager, and she stated Resident #27 does not typically refuse treatments or remove his/her wound dressing. 3. Resident #4 has diagnoses to include hemiparesis (paralysis) following cerebral infarction (stroke). On 4/6/25 at 11:49 a.m., a surveyor observed a brace on Resident #4's left wrist. At this time, Resident #4 stated he/she has had the brace since his/her stroke and that the nursing staff helps him/her put the brace on first thing in morning and take it off at night. Review of Resident #4's care plan stated, .Patient will tolerate left upper extremity wrist brace for no more than 4 hours daily to improve wrist range of motion . A physician progress note, dated 4/1/25, stated, Left hemiparesis .wearing [his/her] brace today Further review of the clinical record lacked evidence of a physician order for the left wrist brace. On 4/9/25 at approximately 1:00 p.m., during an interview, the Director of Rehabilitation and the Occupation Therapist stated their department provided Resident #4's left wrist brace while he/she was receiving therapy, and they would expect to see a physician order for the brace, but that is driven by nursing. On 4/9/25 at 2:10 p.m., the above finding was reviewed with the Market Clinical Advisor and the Director of Nursing.

Based on record review, observations and interviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside in the facility for weekends of the first quarter (October 1, 2024 - December 31, 2024). This has the potential to affect all residents needing assistance with Activities of Daily Living (ADLs). Findings: 1. Review of Payroll Based Journal staffing report revealed the facility triggered for low weekend staffing during the first quarter of 2025 (October 1, 2024 - December 31, 2024). On 4/9/25 at 1:56 p.m., both the surveyor and the Director of Nursing reviewed the weekend staffing from October 1, through December 31, 2024. The Director of Nursing confirmed the facility did not ensure enough staff were on duty to meet resident needs on the weekends. 2. A review of the Resident Council Meeting Minutes revealed the following: -meeting minutes dated 2/26/25 stated Residents are concerned that staffing ratios aren't consistent. Especially 2nd shift, long waits noted .Residents are concerned that call lights are not consistently being responded to timely. -meeting minutes dated 3/26/25 stated, Residents are concerned that there is only one aide per unit on the second shift and they are not consistently available. On 4/6/25 at 10:54 a.m., during an interview, Resident #13 stated the lack of staff is a regular concern at Resident Council meetings and that he/she lets the Administrator know about the complaints about staffing. 3. Review of grievances filed by the Resident Council revealed the following: -a grievance filed 8/12/24 stated, Residents are concerned that call lights aren't consistently being responded to timely. - a grievance filed 9/23/24 stated, Residents are concerned that call lights aren't consistently being responded to timely. 51331

Based on observations and interviews, the facility failed to properly secure medications on 1 of 2 (Short Stay Unit) units for 2 of 4 days of survey, failed to ensure expired medications were removed from the supply available for use in 2 of 4 treatment/medication carts reviewed and failed to ensure expired lab supplies were removed from supply available for use on 2 of 2 units (Short Stay and Long Term Units). Findings: 1. On 4/6/25 at 9:02 a.m., observation of the Short Stay unit to have an unlocked and unattended treatment cart containing 4 residents insulin pens, pen needles and lancets, during this time 2 residents were present. At 9:05 a.m., the Certified Nurses Aid #1 confirmed the unlock treatment cart and locked it. 2. On 4/6/25 at 11:52 a.m., observation of the Short Stay unit medication room with the Licensed Practical Nurse #3 (LPN#3). The surveyor asked if nursing draws their own labs. The LPN#3 stated, We can, yes. I haven't for a while, we have a guy who comes in, he usually brings his own supplies. We will be next week; our guy goes on vacation. On the counter was a plastic tote containing 13 butterfly needles with expiration date of 9/21/24, 5 blue top blood vacutainers with expiration date of 10/31/23 and 6 yellow top vacutainers with expiration date of 1/31/25. The LPN#3 confirmed the supplies available for use were expired and stated there is a lab room on the other unit with additional supplies. 3. On 4/6/25 at 12:10 p.m., observation of the lab room on the long-term care units with the Registered Nurse #3 (RN#3) which contained 46 red top blood vacutainers with expiration date of 4/1/25, 41 white top vacutainers with exp. of 12/1/23, 175 green top vacutainers with exp. date of 12/3/23, 3 dark blue top vacutainers with exp. date of 11/30/24, 34 small yellow vacutainers with exp. date of 3/31/25, 100 gray top vacutainers with exp. date of 11/30/23, and 99 blue top vacutainers with exp. date 4/30/23. At this time, the RN#3 notified the Director of Nursing (DON) who observed the expired vacutainers. The DON stated nurses can draw labs, but they do have a guy who comes in to draw labs and brings his own supplies and will not be available the next week. 4. On 4/7/25 at 6:47 a.m., observation of the Short Stay medication cart unlocked and unattended. The surveyor was able to open and go through the medication cart which contained a bottle of Fish oil 1000 milligram (mg) with and expiration date of 1/11/25 and 21 tabs of Guaifenesin Extended Release tabs with expiration date of 2/25. During this time, 2 staff walked by and observed the surveyor in the medication cart, a Registered Nurse (RN) and Certified Nurses Aid (CNA) neither addressed the unlocked medication cart. At 6:53 a.m., the surveyor asked RN#1, who returned to the area, to lock the medication cart. On 4/7/25 at 6:55 a.m., the above was discussed with the Market Clinical Advisor 5. On 4/7/25 at 9:49 a.m., observation of [NAME] House medication cart with the LPN #2 which contained a blister pack of Fexofenadine 60mg with an expiration date of 10/2024. At this time, the LPN#2 confirmed and removed the expired medication.

Based on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for floors, walls, the dishwasher and fans/vents, failed to ensure staff were wearing proper hair restraints and failed to ensure that canned goods with a compromised seal were not available for use for 1 of 4 days of survey. (4/6/25) Findings: On 4/6/25 at approx. 9:00 a.m., during the initial tour of the kitchen the following was observed: 1. -The kitchen floor was dirty with food debris and trash around the entire floor and under the equipment and shelving. - The kitchen walls were covered with dirt and food debris. - The dish washer was covered with dirt and debris. - The vent above the grill was coated with dirt and debris. - The vents and fans throughout the kitchen had built up dust 2. Observation of the Dietary Aid #1 and #2 not wearing proper hair restraints while preparing food. After surveyor intervention, both Dietary Aid #1 and #2 applied hair restraints. 3. Observation of 3, #10 cans of peaches with denting along the seal and available for use. At this time, the [NAME] #1 stated that cans should be checked for damage upon arrival and if dented, placed in the designated area for compromised cans so they are not available for use. On 4/6/25 at 1:14 p.m., the above information was discussed with the Food Service District Manager.

Based on observations, interviews, and a lunch meal test tray, the facility failed to serve food at an appetizing and palpable temperature for 1 of 2 meals observed. Findings: On 4/6/25 at 9:53 a.m., during an interview, Resident #10 discussed concerns of the food not being hot when it gets to resident. On 4/7/25 at 10:50 a.m., a surveyor requested a sample tray,sample tray. During the observation, both Certified Nursing Assistant (CNA) #2 and CNA #3 started to serve the lunch trays for the 20 residents at 12:19 p.m. During this meal pass, both CNA's had to boost and turn 2 residents and one CNA had to take a resident to the bathroom. The last meal was served at 12:50 p.m., 31 minutes after the first tray was passed. At 12:51 p.m., the food on the sample tray food was tempted, in which the BBQ pulled pork sandwich was 121.7 degrees Fahrenheit and the seasoned potato wedges were 85 degrees Fahrenheit. On 4/7/25 at 1:20 p.m., during an interview, CNA #3 stated they occasionally get more help with passing trays, but it usually ends up being just 2 CNA's which results in cold food. On 4/7/25 at 1:00 p.m., the above information was discussed with the Market Clinical Advisor.

Based on observations, interviews, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to the storage of chemicals being properly secured on 1 of 5 units (Pleasant Hill House) for 1 of 4 days of survey (4/6/25). Findings: 1. On 4/6/25 at 10:07 a.m., observation of room [ROOM NUMBER] on Pleasant Hill House to have an unsecured container of Micro-Kill One Germicidal Alcohol Wipes and a bottle of toilet bowl cleaner. At this time, Registered Nurse #2 confirmed the chemicals should not be stored in a resident's bathroom and removed the chemicals. 2. On 4/6/25 at 11:47 a.m., observation of room [ROOM NUMBER] on Pleasant Hill House to have an unsecured container of Micro-Kill One Germicidal Alcohol Wipes. At this time, Registered Nurse #2 again confirmed that chemicals should not be stored in a resident's bathroom and removed the chemicals. The Safety Data Sheet for Micro-Kill One Germicidal Alcohol Wipes states in Section 4: First Aid Measures. If inhaled: remove person to fresh air and keep comfortable for breathing. Call Poison control center/doctor is you feel unwell . If on skin (or hair): take off immediately all contaminated clothing. Rinse skin with water . If in eyes: Rinse continuously with water for several minutes. Remove contact lenses, if present and easy to do. Continue rinsing. If eye irritation persists, get medical advice/attention . Indigestion: Rinse mouth. Do not induce vomiting. Get medical attention if symptoms occur. Never give anything by mouth if the victim is unconscious or is convulsing. Obtain medical attention. The Safety Data Sheet for 3M Bathroom Disinfectant Cleaner Ready-to-Use states in Section 4: First Aid Measures. Inhalation: Remove person to fresh air. If you feel unwell, get medical attention . Skin Contact: Wash with soap and water. If signs/symptoms develop, get medical attention . Eye contact: Flush with large amounts of water. Remove contact lenses if easy to do. Continue rinsing. If signs/symptoms persist, get medical attention . If swallowed: Rinse mouth. If you feel unwell get medical attention. On 4/9/25 at approx 4:15 p.m., the above information was discussed during exit with the Administer, Director of Nursing and the Market Clinical Advisor

Based on record review and interview, the facility failed to identify a resident's past history of Post-Traumatic Stress Disorder (PTSD)/trauma to determine what trigger(s) might cause re-traumatization and failed to revise the care plan to include those triggers and interventions to prevent re-traumatization for 1 of 2 residents reviewed with a diagnosis of PTSD. (Resident #22) Finding: On 4/6/25 a review of Resident #22's medical record showed he/she was admitted in 2018 and had a current diagnosis of PTSD. Further review including assessments and the current care plan lacked evidence that the facility assessed the resident for what triggers might cause re-traumatization and failed to revise the care plan to include those triggers and interventions to prevent re-traumatization. On 4/7/25 at 3:30 p.m., during an interview, the Market Clinical Advisor confirmed the above and stated that nursing completed a trauma assessment today on Resident #22 which included triggers that may cause re-traumatization.

Based on record review, observation, and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 2 residents reviewed for nutrition (Resident #11). Finding: Resident #11 was admitted in 2024 with diagnoses to include protein-calorie malnutrition. Resident #11's clinical records contained an active physician order dated 1/17/25 for Start 8oz whole milk & full fat ice cream milkshake TID w/ meals and at bedtime with meals AND at bedtime. A physician progress note, dated 2/28/25 which stated, Did verify with staff that [he/she] is being given whole milk with [his/her] shakes however, unable to find the order for milkshakes on the MAR (Medication Administration Record) or TAR (Treatment Administration Record). Did discuss this with unit manager . An additional physician progress note, dated 4/1/25 which stated, Weight loss .still do not see order for milkshakes on MAR or TAR to be signed out, will discuss with nurse manager again . Resident #11's MAR and TAR for January, February, and March 2025 lacked documentation of the milkshakes being given. On 4/8/25 at 8:51 a.m., during an interview with a surveyor, the unit manager reviewed Resident #11's entire clinical record and confirmed the January, February, and March 2025 MAR/TAR lacked evidence of Resident #11 being given and/or refusing a milkshake. On 4/8/25 at 11:44 a.m., the above was discussed with the Market Clinical Advisor.

Based on record review, interviews, and facility policy, the facility failed to thoroughly investigate an Injury of Unknown Origin for 1 of 1 resident reviewed for Injuries of Unknown Origin. (Resident #57) Findings: On 10/5/24 the Division of Licensing and Certification received a report that Resident #57 obtained an injury to his/her left ankle, while an unknown Certified Nursing Assistant was putting on the resident's shoe. Review of Resident #57 medical record contained a provider note, dated 10/4/24 of an evaluation of his/her left ankle, which resulted in the provider ordering an X-Ray. On 10/5/24 an X-Ray was obtained and showed no evidence of a fracture but showed soft tissue swelling. Further review of the medical record lacked evidence of any nursing documentation of an injury occurring or monitoring of his/her left foot. Review of the facility's investigation dated 10/7/24, consisted of the Director of Nursing's interview with Resident #57 and a family member, and a note from an Occupational Therapy (OT) student dated 10/7/24. The OT students note states that Resident #57 Reported to the OT student that his/her left leg hurt very badly and was bruised and swollen. Patient showed OT his/her left lower extremity, there was bruising on the anterior aspect of his/her knee and swelling with slight bruising on his/her left ankle. Patient reported that the injury occurred from an aid that was trying to help him/her put his/her shoes on but was painfully twisting his/her leg. Further review of the facilities investigation lacked evidence that the Director of Nursing thoroughly investigated Resident #57 injury of unknown origin by completing observations and interviews with staff who was working with Resident #57. The facility policy Abuse Prohibition, last revised on 10/24/22 states in Section 7, subsection 7.7 Initiate an investigation within 24 hours of an allegation of abuse that focuses on whether abuse or neglect occurred and to what extent, clinical examination of signs and symptoms of injuries, if indicated, causative factors, and interventions to prevent further injury . The investigation will be thoroughly documented within the Risk Management Portal. Ensure that documentation of witnesses is included. On 4/8/25 at 11:20 p.m., during an interview, the Market Clinical Advisor was unable to find any additional documentation in the risk management portal or further investigations.

Based on record reviews, and interviews, the facility failed to provide evidence to show Advance Directives were offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an Advance Directive, for 4 of 14 residents reviewed for Advance Directives. (Resident#12, #18, #2 and #19) Findings: 1. Resident #12 was admitted to the facility in February 2025. A review of the residents electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. 2. Resident #18 was admitted to the facility in December 2024. A review of the residents electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. On 4/6/25 at 3:00 p.m., the above information was Discussed with the Market Clinical Advisor. 51669 3. Resident #2 was admitted in December 2024. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 4. Resident #19 was admitted in December 2024. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. On 4/8/25 at 4:15 p.m., the above findings were reviewed with the Market Clinical Advisor.

Based on observations and interview, the facility failed to maintain a clean/sanitary environment on 1 of the 3 units. (Oak Hill House). Findings: On 10/7/24 at 9:14 a.m., the Department of Licensing received a complaint indicating that the bathrooms on the Oak Hill Unit were very dirty and smelled of an odor that resembled 'urine'. On 10/15/24 at 9:35 a.m., in an interview, the Housekeeping Manager stated that there are issues with the floors in some of the bathrooms on the Oak Hill Unit and that the floors tiles are loose, but they are afraid to use a scrubber & buffing machine on them because the tiles may become loose. On 10/15/24 at 9:45 a.m., during a tour, a surveyor observed the residents' bathrooms on the Oak Hill Unit. All resident bathroom floors were observed to have a buildup of wax and dirt. Bathrooms #2, #3, and #7 were observed to have extensive wax buildup. During the observation of bathroom [ROOM NUMBER], there was an overwhelming odor of what resembled urine. At this time the Housekeeping Manager confirmed the above findings. On 10/15/24 at 10:15 a.m., in an interview, the Maintenance Supervisor stated that the floors in the bathrooms on the Oak Hill Unit have been worked on in the past but should be cleaned by whatever means the Housekeepers need to use, to get them clean. If there is damage to the floors in the process, then he will have the floors fixed. On 10/15/24 at 1:00 p.m., a surveyor confirmed the above findings with the Administrator. . .

Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment on 2 of 2 units and in the Kitchen. Findings: 1. On 3/3/24 at 9:10 a.m., during the initial observation of the Kitchen with the cook, it was observed that the ceiling had multiple ceiling tiles that had moderate to heavy amounts of spotting and staining. On 3/6/24 at 11:15 a.m., in an interview with the Director of Maintenance, he stated that the Kitchen ceiling had not been cleaned in the [AGE] years that he has been here. He stated, I would not know how you would clean that. 2. On 3/6/24 at 11:20 a.m., during a tour of the Long Term Care Unit with the Director of Maintenance the following were observed: - Pleasant Hill House, resident room [ROOM NUMBER], the window curtains were off the track on both sides of the window. One stained ceiling tile at the nurses' station and 1 stained ceiling tile in the resident dining room. 3, On 3/6024 at 11:40 a.m., during a tour of the Short Stay Unit with the Director of Maintenance, the following were observed: - Stained ceiling tiles in resident room [ROOM NUMBER], just over the bed. - One stained ceiling tile at the Nurse's station, and one stained ceiling tile in the hallway just outside the dining room. The Director of Maintenance was made aware of the findings at that time and recorded them.

Based on interviews, record reviews and observations, the facility failed to provide sufficient staffing to meet the acuity level and resident needs in a timely manner for 3 out of 3 units surveyed. (Pleasant Hill House, [NAME] House and Oak Hill House) Findings: 1. On [DATE] at 9:17 a.m a surveyor observed Resident #14 asking a CNA #2 for a shower. Resident #14 stated they should have gotten a shower on Friday but was told there wasn't enough staff that day. And it happened last week too. CNA #2 confirmed the resident's scheduled shower day was Thursday and it hadn't happened yet this week. A record review of Resident #14's bathing documentation revealed only 1 documented shower in the past 63 days. On [DATE] 9:30 a.m., a surveyor interviewed CNA #5, There's a lot I can't get to. Changing, repositioning, it doesn't happen. Things we are supposed to do but can't get to it. I spend all my time looking for someone to help me. I find them and then I have to wait because they're busy. We should have 2 people over here. On [DATE] at 9:35 a.m., a surveyor interviewed CNA #3 We can't give the care we need because there isn't enough staff It's disruptive to my med pass when I am constantly pulled away from the med cart When asked if it feels safe to have so many disruptions during a medication pass, CNA #3 replied No. 2. On [DATE] at 9:38 a.m., a surveyor observed a call bell on Oak Hill Unit go unanswered for 40 minutes. 3. On [DATE] at 10:10 a.m., a surveyor interviewed Resident #17 and learned that she/he had requested to get up at 6:00 a.m. and wasn't helped up until 10:00 a.m. after being told they didn't have enough staff yet. 4. On [DATE] at 9:16 a.m., during an interview with CNA #2 and was told there is no support from licensed staff and that most wait for the CNAs to answer the call bells. 5. On [DATE] at 9:00 a.m., a surveyor interviewed Resident #12 after observing a 40 minute wait for the call bell to be answered. The resident stated it usually takes ,d+[DATE] minutes for someone to answer the call bell. That is not unusual. 6. On [DATE] at 9:05 a.m., a surveyor interviewed Resident #18 who said staffing was a problem, especially on the weekends; My roommate and I have talked and we feel like if we died on a Friday afternoon, that no one would find us until Monday morning 7. On [DATE] at 10:35 a.m., a surveyor interviewed Resident #14 who stated that the food was frequently cold by the time it was passed and the CNAs had to waste time heating up the food because it was always cold. 8. On [DATE] at 9:45 a.m., a surveyor interviewed CNA #1 and learned that 11 out of 39 residents on Pleasant Hill, [NAME] House and Oak Hill Units always need 2 staff members for care but sometimes it's more. It's hard to find someone to help explaining they get stuck in a room with a resident and can't get to the lights or they are waiting for someone to come help. 9. On [DATE] at 10:54 a.m., a surveyor observed CNA #1 come to the nursing station to request assistance and the licensed staff replied, Ok but this is why I don't get my dressings done. During an interview with the CNA #1 afterwards, she/he revealed that That nurse is one of the first ones to help when we ask but most don't. On [DATE] at 1:00 p.m., a surveyor brought the above findings to the attention of the Director of Nursing.